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Complaints, grievances and appeals

We want you to be happy with the care you get. So if you’re ever unhappy with your health plan or a provider, you can file a complaint/grievance. And if you’re unhappy with a decision we made, you can file an appeal. This process helps us make our services better.

 

To learn more, just visit our Materials and forms page to check your member handbook.

Help us better serve you

Help us better serve you

A complaint/grievance

 

You’re unhappy with the quality of care or services you received from:

 

  • One of your providers (for example, vision or dental services providers) 

  • A pharmacy or hospital

  • Your health plan 

 

Here are some things you can file a complaint/grievance about:

 

  • You were unhappy with the quality of care or treatment you received.
  • Your provider or a plan staff member was rude to you or didn’t respect your rights.
  • You had trouble getting an appointment with your provider in a reasonable amount of time.
  • Your provider or a plan staff member wasn’t sensitive to your cultural needs or other special needs you may have.

Do you have a complaint/grievance? Filing a complaint/grievance or appeal won’t affect your health care services or benefits coverage. Just let us know right away. We have special processes to help you. And we’ll do our best to answer your questions and resolve your issue. 

 

An appeal

 

This means you disagree with a decision we made about your coverage for services your provider believes are medically necessary. You’ll get a letter from us if we deny, stop, hold or reduce an ongoing service or treatment you’ve been receiving.

 

Then, if you like, you can file an appeal. You’d like us to review the decision to be sure we were correct about things like:

 

  • Not approving a service your provider asked for
  • Stopping a service that was approved before
  • Not paying for a service your primary care physician (PCP) or other provider requested
  • Not giving you the service in a timely manner
  • Not approving a service for you because it was not in our network

Your appeal will be reviewed by a provider with the same or like specialty as your treating provider. The reviewer won’t:

 

  • Be the same provider who made the original decision to deny, reduce or stop the service
  • Report to the provider who made the original decision about your case  

File here

I want to file a complaint/grievance or appeal

 

You have options for filing a complaint/grievance or appeal. And we’re here to help you through the process. If you don’t speak English, we can provide an interpreter at no cost.

What happens next?

What happens next?

  • Within 60 calendar days from the date on our decision letter: You or your representative need to file the appeal.
  • Within 30 calendar days (standard appeal): We’ll tell you our decision. 
  • Up to 14 days: We may extend the decision time about your appeal if we need more info and the delay is in your interest. If we extend the time, we’ll send you a letter to explain the delay. You can also ask for more time if you need it.

Expedited or quick appeal

 

  • Within 72 hours (Medallion and CCC Plus) or within 48 hours (FAMIS): We’ll tell you our decision if your appeal is for urgent, emergency or hospital care. Or if waiting up to 15 days for a decision could be harmful to your health.

You have other appeal rights. You can also:

 

  • Send us any information you think is important to your appeal
  • Ask to see your file anytime in the process
  • Attend the appeal committee review (or have a doctor or representative attend in your place)

Just contact us if you’d like to attend the appeal committee review.

More help with complaints/grievances and appeals

If you need more help or don’t agree with our appeal decision, here are some options.

You can have someone else file a complaint/grievance or appeal for you. They can also act for you in a state fair hearing. This person is your member representative. They may be:

 

  • Your provider
  • Your family member
  • Your friend
  • Your legal guardian
  • Your attorney
  • Another person 

 

You have to give written permission to the person allowing them to act for you. You’ll need to write a letter for:

 

  • Complaints/grievances
  • Appeals
  • State fair hearings (Medallion and CCC Plus): Send the letter to the Division of Appeals – Department of Medical Assistance Services (DMAS) and include it with your state fair hearing request.

If you write a letter, tell us that you want someone else to act for you to file a complaint/grievance or appeal. Be sure to include:

 

  • Your name
  • Your member ID number from your ID card
  • The name of the person you want to represent you
  • What your complaint/grievance or appeal is about

 

Then, sign the letter and send it to:

 

Aetna Better Health® of Virginia
Attn: Appeals Department
PO Box 81139
5801 Postal Road
Cleveland, OH 44181
Fax: 866-669-2459

 

Is your provider filing on your behalf? If yes, be sure they use this address, not the provider address.

 

When we get the letter, the person you chose can act for you. If someone else files a complaint/grievance or appeal for you, you can’t file one yourself about the same item.

You can speed up your appeal if waiting is harmful to your health. This is a fast or expedited appeal. Just contact us (either you or your provider can). We’ll call you with the decision within 72 hours (Medallion and CCC Plus) or 48 hours (FAMIS). We can increase the review period up to 14 days if you ask for an extension or we need more info and the delay is in your interest.

 

You can also ask for a fast appeal in situations that involve:

 

  • Urgent or emergency care
  • A new or continued hospital stay
  • Availability of care
  • Health care services for which you have received emergency services but haven’t yet been discharged from a hospital or other facility

 

If we can’t approve a fast appeal, we’ll call to let you know. We’ll also send you a letter. Then, we’ll process your appeal normally, in the usual timeframe (30 days).

Was your appeal based on a decision to deny, stop, change or reduce an ongoing service or treatment? If so, and our decision on your internal appeal isn’t in your favor, you can request an external review in writing within 30 days of our appeal decision letter. This review isn’t connected with our plan.

 

To ask for an external review, send your letter to:

 

FAMIS External Review

c/o KePro

2810 N. Parham Rd.

Suite #305

Henrico, VA 23294

Was your appeal based on a decision to deny, stop, change or reduce an ongoing service or treatment? You can ask for a state fair hearing from the Division of Appeals – Department of Medical Assistance (DMAS) if you don’t agree with our appeal decision. The state’s rules say you must wait for your internal appeal to be complete first.

 

You must also ask for a state fair hearing in writing or online within 120 days of the date of the appeal decision letter from your internal appeal.

 

You can send your request for a state fair hearing to:

 

Division of Appeals

Department of Medical Assistance Services (DMAS)

600 E. Broad Street, Suite 1300

Richmond, VA 23219

 

You may visit www.dmas.virginia.gov/#/appealsresources to set up an account on the Appeals Information Management (AIMS) portal. This will allow you to track and manage your appeal online, view important dates and notices, and submit documentation.

 

Your language, your format



You need to understand your rights when it comes to complaints/grievances and appeals. Do you need info in another language? Just contact us. We’re here for you 24 hours a day, 7 days a week. We’ll share this info in your primary language. You can also get info other formats, like large print or braille.